late-lifedepressivesymptoms,religiousness,and

Hindawi Publishing CorporationDepression Research and TreatmentVolume 2012, Article ID 754031, 10 pagesdoi:10.1155/2012/754031

Research Article

Late-Life Depressive Symptoms, Religiousness, andMood in the Last Week of Life

Arjan W. Braam,1, 2 Marianne Klinkenberg,3 Henrike Galenkamp,1 and Dorly J. H. Deeg1

1 Longitudinal Aging Study Amsterdam, Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research,VU University Medical Center Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands

2 Department of Emergency Psychiatry & Department of Specialist Training, Altrecht Geestelijke Gezondheidszorg,Utrecht, The Netherlands

3 Integraal Kankercentrum Nederland, Amsterdam, The Netherlands

Correspondence should be addressed to Arjan W. Braam, [email protected]

Received 31 January 2012; Revised 23 March 2012; Accepted 20 April 2012

Academic Editor: Raphael M. Bonelli

Copyright © 2012 Arjan W. Braam et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Aim of the current study is to examine whether previous depressive symptoms modify possible effects of religiousness on moodin the last week of life. After-death interviews with proxy respondents of deceased sample members of the Longitudinal AgingStudy Amsterdam provided information on depressed mood in the last week of life, as well as on the presence of a sense of peacewith the approaching end of life. Other characteristics were derived from interviews with the sample members when still alive.Significant interactions were identified between measures of religiousness and previous depressive symptoms (CES-D scores)in their associations with mood in the last week of life. Among those with previous depressive symptoms, church-membership,church-attendance and salience of religion were associated with a greater likelihood of depressed mood in the last week of life.Among those without previous depressive symptoms, church-attendance and salience of religion were associated with a higherlikelihood of a sense of peace. For older adults in the last phase of life, supportive effects of religiousness were more or less expected.Fore those with recent depressive symptoms, however, religiousness might involve a component of existential doubt.

1. Introduction

One important aspect of religion is how it may guide peoplethrough questions about the end of life. For some religiousbelievers, it is clear that death only implies a transition.Others are less convinced, and may doubt about the existenceof a transition, or about the conclusion of a judgement ontheir moral behaviour. In a previous study, we focused onthe role of religiousness with respect to aspects of mood inthe last week of life, as observed in a sample of older adultsin The Netherlands [1]. Several aspects of religiousness wereincluded, but none of them was associated with depressedmood in the last week of life, as reported by surviving rela-tives. Nonetheless, church attendance earlier in life predicteda “sense of peace” with the approaching end of life. There-fore, only modest support was found for the adaptive poten-tial of religion in the last week of life. A possibly maladaptive

aspect was not identified in this first report. Furthermore—although the analyses were adjusted for effects of previousdepressive symptoms—the first study did not focus on thosewho were prone to depression during their lifetime.

The Netherlands represents a highly secularized country,but the older generation has still grown up in a society inwhich religious traditions had a prominent role, and manyolder people still endorse religious beliefs [2]. An ongoingdebate in The Netherlands, especially among psychologistsof religion and mental health professionals, is about the ques-tion whether religious beliefs, instead of giving support, mayprovoke depressive symptoms, such as feelings of guilt [3].Indeed, for older people with a depressive syndrome, feelingsof guilt were more often reported for the Calvinist Protes-tants and Roman Catholics, compared to nonchurch mem-bers [4]. The same was true for complaints of psychomo-tor inhibition, especially among depressed Protestants, but

2 Depression Research and Treatment

among the nondepressed, there were no denominationaldifferences in guilt or psychomotor inhibition. Therefore, therelationship between facets of religiousness and mood seemsto differ between the depressed and the nondepressed.

The last phase of life may follow different trajectories,such as with a gradual or rapid physical decline, and the men-tal demands will vary across the different types of illness. Thelast phase of life is characterized by inevitable adjustmentsfor many older adults. There is a large need of informal andformal care, and many have to face a transfer to a differentliving environment [5]. In a recent study from the US, Huiand colleagues described fairly high levels of spiritual distress(such as feeling despair and brokenness, from an existentialpoint of view) among patients with advanced cancer [6]. Asexpected, spiritual distress was associated with depression.

On the other hand, several studies among terminally illpatients showed associations between Spiritual Well-beingScale scores and lower levels of psychological distress [7, 8].As some content overlap may occur between spiritual well-being and emotional well-being (or its reverse, psychologicaldistress), these studies included statistical adjustment fordepressive symptoms. Which aspects of religiousness andspirituality specifically determined the association withpsychological distress in the terminally ill is difficult to saybecause the measure of spiritual well-being combines severalaspects. One study included the belief in a hereafter as adistinct variable, and this was associated with lower levels ofhopelessness, but not with feelings of anxiety or depression[9]. A complementary finding by Van Laarhoven and col-leagues, in a small sample of advanced cancer patients, wasthe association of an explicit agnostic perspective on deathand afterlife with higher levels of hopelessness [10]. Theauthors also described a negative association, but only at anonsignificant level, between an explicit religious attitudeand depression. In a palliative care study, a significantnegative association with depression or anxiety disorder wasfound for church-attendance, but not for religious affiliation,prayer, or subjective religiousness [11].

With respect to the association between religiousnessand the course of depression, several studies (from the US,Netherlands, and Australia), have shown that intrinsic reli-gious motivation (or salience of religion) was associated witha quicker remission of the depression [12]. Findings in theliterature about the association between church-attendanceand the course of depression are however less consistent [13].

Clinical experience and epidemiological evidence havemade clear that depression and depressive symptoms (or“subthreshold” depression) tend to recur, and for a minority,to persist, also in later life [14–16]. Therefore, the bestpredictor of depression is previous depression, and likewise,we expect that the vulnerability to depression will alsopredict depressed mood in terminal patients. With respectto the possible role of religiousness in this last phase oflife, little is known about how an existing vulnerability todepression interferes with supportive or undermining effectsof religiousness.

The current, population-based study focuses on relation-ships between aspects of religiousness and mood in the lastweek of life, as reported by surviving relatives of deceased

sample members of the Longitudinal Aging Study Amster-dam (LASA) [17]. Information on religiousness was alsoobtained from the LASA respondents who were interviewedduring lifetime about several aspects of religious life, aswell as about depressive symptoms. In our previous study,we found that previous depressive symptoms predicteddepressed mood, anxiety, and lack of sense of peace in the lastweek of life [1]. The current study aims to examine whetherprevious depressive symptoms modify associations betweenaspects of religiousness and mood in the last week of life,either giving way to a supportive potential of religiousness(e.g., for salience of religion), or to maladaptive effects (e.g.,for certain convictions such as belief in hell).

2. Methods

2.1. Sample. The Longitudinal Aging Study Amsterdam(LASA) is an ongoing interdisciplinary study on predictorsand consequences of changes in autonomy and well-beingin the aging population. The LASA cohort is based on anationwide random sample of older adults between the agesof 55 and 85, stratified for age, sex, and expected mortalityfive years into the study. Registries of 11 municipalities inareas in the West (mostly secularized, including Amsterdam),North-east (predominantly Protestant), and South (predom-inantly Roman Catholic) of The Netherlands provided thesampling frame [18, 19]. The realized number of respondentsin the LASA baseline interview cycle in 1992/1993 amountedto 3,107. Respondents were interviewed in their homesby intensively supervised interviewers. Three years later,in 1995/1996, all respondents were approached for the T2interview cycle. The participation rates and numbers ofdecedent respondents are shown in Figure 1. Between T2and T3 (1998/1999), 342 respondents died. The database ofLASA contains contact information about two persons closeto the sample member, such as the partner, a child, sibling, orother person who had had close contact. Wherever possible,one proxy respondent was selected, who had been involvedin the last three months of the sample member, and whowas willing and able to participate. The proxy respondentwas approached with a letter with information on the study,followed by a telephone call, to make an appointment forthe interview, which was held in the home of the proxyrespondent. This research method is known in the literatureas “retrospective/after-death approach” or “proxy interview”[20]. The number of proxy respondents amounted to 270,mainly children (50%) and spouses (33%) of the samplemembers.

2.2. Measures

2.2.1. Mood in the Last Week of Life. The interview with theproxy respondent included a one-item question on whetherthe sample member showed feelings of depression in thelast week of life. Scores were 0 (absence of depressed mood)or 1 (presence of depressed mood). Furthermore, the proxyrespondents were asked to estimate whether the samplemember experienced a sense of peace with the approaching

Depression Research and Treatment 3

T1: 1992/1993interviewN = 3, 107

T2: 1995/1996interviewN = 2, 545

Died 417

Not contacted 17

Unwilling 90

Unable 38

T3: 1998-1999

Died 342

Proxy interviewN = 270

No proxy 42contacted

Unwilling 30

Last week of life

(net response 62%)

(net response 95%)

(response 79%)

Figure 1: Flowchart of sampling times of the proxy interviews of deceased respondents of the Longitudinal Aging Study Amsterdam betweenT2-T3.

end of life. This was scored as 0 (sense of peace-absent) or 1(sense of peace present).

2.2.2. Religiousness. Data on religious affiliation and churchattendance were obtained during the first assessment cycleof LASA. Religious affiliation included: Protestant, RomanCatholic, and nonreligious affiliation. The Protestant groupconsisted of several denominations, but most with originsin the Reformed/Calvinist protestant tradition. The religiousaffiliation of the parents was also asked, and was coded as:(1) both parents and sample member affiliated; (2) parentsaffiliated, sample member not affiliated (first generationsecularized); (3) neither parents nor sample member affil-iated (second generation secularized). Church-attendancewas assessed using five response categories, ranging from“once a year or less” (1) to “once a week or more” (5).

The second LASA assessment cycle contained question-naires on orthodox religious beliefs and salience of religion.The level of adherence to traditional (Christian) religiousbeliefs was assessed at T2 by the Orthodoxy Scale, whichhas been regularly used in studies by the Dutch Social andCultural Planning Office (SCP) [2]. Doctrines included are(asked as “Do you believe in”): life after death, heaven,purgatory, hell, the devil, the actual existence of Adam andEve, and the Bible as God’s word. Answer could be “yes”(score = 1) or “no” (score = 0), yielding a score range of 0–7(Cronbach’s alpha 0.86).

Salience of religion was assessed using two items of areligious salience scale [21]: “My religious faith/philosophyof life has a pronounced impact on my daily life” and “WhenI take important decisions, my religious faith/philosophyof life plays a considerable role.” Response categories rangebetween “totally disagree” (0) to “totally agree” (5). Salienceof religion was also probed in the proxy interview, using thesame items (“Salience-according-to-proxy”).

2.2.3. Previous Depressive Symptoms Assessed in the LASARespondent Interview. Depressive symptoms were measuredusing the Center for Epidemiologic Studies Depression Scale[22]. Subjects were asked how often they experienced eachof 20 symptoms during the previous week. The responsecategories ranged from 0 (“rarely or none of the time”) to3 (“most of or all the time”), yielding a score range of 0 to60 (Cronbach α = 0.83). A CES-D score of 16 or higherhas generally been used as indicative for clinically relevantdepressive symptoms, including both minor or subthresholddepression and major depression [23, 24]. Therefore, in thestratified analyses, this cutoff was applied.

2.2.4. Covariates from the LASA Respondent Interview. Demo-graphic characteristics of the sample member included age ofdeath, sex, education in years, and marital status (marriedversus widowed, divorced, or never married).

The number of major chronic diseases was assessed at T2,by explicitly asking the respondents whether or not they hador had had any of the following seven conditions: chroniclung disease, cardiac disease, peripheral artery disease,stroke, diabetes mellitus, arthritis, and cancer [25].

2.2.5. Covariates from the Proxy Interview

Physical State. The proxy respondents were asked about thepresence of serious physical symptoms in the last week oflife of the sample member: fatigue, pain, shortness of breath,confusion, and nausea and/or vomiting. Responses (0 “no”and 1 “yes”) were summed to obtain a symptom burdenscore (range 0–5).

Cognitive change between the measurement in 1995/1996and 3 months before death was assessed using the six-itemshort form Informant Questionnaire on Cognitive Declinein the Elderly [26]. For every item, the proxy respondent


answered on a five-point scale (range 1–5; Cronbach α =0.93). Higher sum scores indicate cognitive decline.

Time Intervals. The duration of the periods between theT2 interview and death, and between death and the proxyinterview were included to adjust for any influence of timeon the outcomes.

Whether the sample members had expected death andhad been aware of the approaching end was estimated by theproxy respondents, with “yes,” “no,” or “more or less” as re-sponse categories. When both questions were answered with“yes,” it is assumed that the sample member clearly realizedthe approaching end.

2.3. Statistical Procedure. In the previous paper, associationswith the two outcome variables on mood in the last week oflife—feeling depressed and sense of peace—were analysed foreach of the religious variables, using logistic regression anal-ysis, computing odds ratios (OR) and 95% confidence inter-vals (95% CI) [1]. Adjustment was made for the covariateswith significant associations with the dependent variables, aswas evident from prior bivariate and multivariate analyses(also carried out in the stratified subgroups of interest withand without previous depressive symptoms). As there wasvariation in item nonresponse between the variables, themaximal number of sample members was included in eachof the analyses.

Modification of the association with the outcome vari-ables was examined by including the product term betweenprevious depressive symptoms as assessed on T2 (79%)or on T1 (21%, with missing scores at T2) and each ofthe religion variables in the subsequent logistic regressionmodels. To avoid multicollinearity between first-order termsand product terms, product terms were formed by multiply-ing the centered (deviation from the mean) scores of bothcomponents [27]. The level of statistical significance was setat P < 0.05 for main effects, and at P < 0.10 for interactioneffects, as the power of statistical tests for higher order termsis generally lower than for first order terms [27, 28]. Tofacilitate interpretation of the interactions, the associationsbetween the religion variables and the outcome variableswere examined using logistic regression analyses, adjustedfor relevant covariates and stratified for two contrastingsubgroups: those who had low levels of depressive symptomsat a previous assessment (CES-D score < 16) and those whohad high levels of depressive symptoms (CES-D ≥ 16).

3. Results

3.1. Characteristics of the Sample. The majority of the sample(Table 1) was male, which is in accordance with the higherexpected mortality among males. Mean age of deathamounted to 80 years. About one-third was Protestant, one-third Roman Catholic, and one-third nonaffiliated. One-third of the sample members used to attend church on aweekly basis. As examples of items of the orthodoxy, 57%of the sample members reported to believe in heaven, and30% reported to believe in hell. Salience of religion received

higher scores by the sample members at T2, compared tothe report by the proxy respondents. The Cohen κ for inter-rater agreement was fair for both salience items (.27 and .25).Depressed mood in the last week of life was reported for 28%of the sample members and sense of peace for 76%.

Bivariate associations between covariates and mood in thepast week of life have been reported in the previous publica-tion [1]. Depressive symptoms, assessed in previous LASAinterviews, significantly predicted the presence of depressedmood in the last week of life (t = −2.9, P = .005), as well asthe absence of a sense of peace (t = 4.3, P = .000). Neitherthe duration of the period between the T2 interview anddeath, nor the duration between death and the proxy inter-view had significant associations with depressed mood (t =0.6, P = .573; t = −1.1, P = .263) or with sense of peace (t =−0.7, P = .459; t = 0.2, P = .869). These time periods didnot significantly interact with depressive symptoms assessedin the previous LASA interview and depressed mood or senseof peace in the last week of life (results on request). Similarly,the type of relationship between the respondent and theproxy (whether or not this was the partner or child) did notinteract with the association between depressive symptomsand mood in the last week of life (results on request).

Serious physical symptoms and cognitive decline weresignificantly associated with depressed mood in the last weekof life (t = −4.2, P < .001, and t = −2.6, P = .009, resp.).In contrast, cognitive decline and higher age were positivelyassociated with a sense of peace (t = 2.0, P = .043; t = 2.3,P = .024).

3.2. Interactions with Previous Depressive Symptoms. The re-sults of the tests for interactions are shown in Table 2. Fordepressed mood in the last week of life, previous depressivesymptoms significantly interacted with religious affiliation,church-attendance, and orthodox beliefs. For sense of peace,previous depressive symptoms significantly interacted withreligious affiliation, church-attendance, and salience accord-ing to proxy. The nature of the interactions is illustratedusing stratified analyses. Table 3 summarizes the associationsbetween the religious variables and the proxy’s reports ondepressed mood and sense of peace in the last week of life,both for those who had high and low CES-D scores at anearlier assessment. Two main patterns emerge.

First, among those with previous depressive symptoms(CES-D ≥ 16), there was a significantly higher risk ofdepressed mood in the last week of life for those who wereaffiliated with a church, for those who attended church ona more frequent basis, and for those for whom religion wassalient according to the proxy respondent. Although only atthe level of a statistical trend, the same was found for thosewith higher orthodoxy scores. No significant association wasfound between salience of religion and depressed mood inthe last week of life.

The second pattern pertains to the other outcome, senseof peace in the last week of life. Here, for those withoutprevious depressive symptoms (CES-D < 16), there was ahigher chance on a sense of peace for those who used to goto church on a regular basis, and for those for whom religionwas salient according to the proxy respondent.


Table 1: Characteristics of deceased sample members of the Longitudinal Aging Study Amsterdam (LASA) between 1995 and 1998.

n Range Mean (SD) %

Sex (% female) 270 38.1

Age of death 270 59–91 80.4 (7.5)

Time interval: last respondent interview–death (days) 269 8–1321 589 (330)

Time interval: death proxy interview (days) 270 131–1479 789 (316)

Last respondent interview

Marital state (% married) 263 47.1

Education (years) 263 5–18 8.6 (3.4)

Number of major chronic diseases 270 0–7 1.6 (1.2)

Depressive symptoms (% ≥16) [n = 56 at T1, n = 211 at T2] 267 0–44 10.4 (8.6) 21.7

Religious affiliation 270

Protestant 31.9

Roman Catholic 28.9

Other 1.5

Nonaffiliated(2) 37.8

Church attendance in 1992 (LASA baseline interview) 270 1–5 2.7 (1.8)

Orthodoxy scale 203 0–6 2.9 (2.3)

Salience of religion, last interview with sample member 203 0–8 5.1 (2.1)

Interview with proxy respondent

Cognitive decline according to proxy respondent (1) 238 1–5 3.8 (0.8)

Serious physical symptoms in the last week of life(1) 259 0–5 2.2 (1.3)

Mood in last week of life according to proxy respondent

Depressed mood 233 28.2

Sense of peace—absent 204 23.5

Salience of religion according to proxy respondent 268 0–8 3.5 (3.1)

Expected death/aware of approaching end (both “yes”, %) 270 53.0(1)

High scores indicate more problems.(2)Among the nonaffiliated: one or both parent(s) affiliated 61% (n = 59) and both parents nonaffiliated 39% (n = 38) (9 had missing value).

3.3. Denominational Background. Additional analyses(Table 4) revealed that among those with previous depressivesymptoms, the risk of depressed mood was, at trend level,somewhat more evident for Roman Catholics, compared tothe nonaffiliated. Among those without previous depressivesymptoms, affiliation showed a gradual increase in thelikelihood of experiencing a sense of peace in the lastweek of life; compared to second generation secularized,the difference for the first generation secularized wasnot significant (OR 2.46), reached trend-level for RomanCatholics (OR 3.15), and was significant for Protestants(OR 3.52). The confidence intervals showed, however, aconsiderable overlap, indicating that the differences betweenthe three denominational groups do not differ significantly.

4. Discussion

The current contribution focused on the role of religiousnessin the association between previous depressive symptomsand mood in the last week of life. Information was partlyobtained from interviews, as the sample members partici-pated in a prospective population-based study, and partly

from after-death interviews with relatives of the deceasedsample members.

The previous report on these data showed that there wereno significant associations between aspects of religiousnessand depressed mood in the last week of life in the fullsample [1]. However, the current study shows that amongthose with previous depressive symptoms in the last interviewcycle (on average about two years before death), severalaspects of religiousness were associated with an increasedlikelihood of depressed mood in the last week of life:church-attendance, (Roman Catholic) church-membership,and salience of religion (salience-according-to-proxy).

In contrast, among those without previous depressivesymptoms, church-attendance, church-membership, andsalience of religion (salience-according-to-proxy) were asso-ciated with a higher likelihood of a sense of peace with theapproaching end of life. This sense of peace had the lowestreports among the nonchurch members with nonaffiliatedparents (second generation secularized).

The finding that religiousness is associated with de-pressed mood in the last week of life for those whohad previous depressive symptoms, at least at the level of


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subthreshold depression, is appealing and raises the questionwhat mechanism is at work. In discussing theories ondeath anxiety, Kastenbaum considers that death concernbelongs to the core Christian conceptions [29]. He statesthat it is possible that Christian doctrine may intensify bothanxiety, living in dread of judgment, and serenity, evenwith longing and impatience. Kastenbaum calls for moreelaborate empirical research to understand the psychologicaland social key factors through which individuals and familiescome to terms with both the “dread” and the “welcome” ofChristian death. The current results seem to offer empiricalsupport for the existence of both positions.

Church-attendance showed the greatest contrast betweenthose with and without previous depressive episodes. Thelevel of orthodoxy of Christian beliefs showed a contrastas well, but was significant only at the level of a statisticaltrend in those with previous depressive symptoms. Thus, thecognitive (doctrinal) aspects of religiousness do not seemto represent the main explanation, whereas behavioural andmotivational aspects (as measured with church-attendanceand salience of religion) do come to the fore. The emotionalfacet, the feeling of being accepted by the deity, or aban-doned, could be even more central. Especially feelings ofabandonment by God are known to have high correlationswith depression, and, hypothetically, may result in a deepercrisis when the belief in sustainment by the deity seems tobe out of grasp [30]. Future research should also address theemotional facet of religiousness in this context.

In the current sample of older adults, there was stillconsiderable membership of religious denominations, butthe nonaffiliated represented a sizable group. About one-third of this group had nonaffiliated parents as well. Themain impression is that the nonaffiliated had the leastdisadvantages (least depressed mood in the last week of life)in case of previous depressive symptoms. On the other hand,for those without previous depressive symptoms, the non-affiliated who had nonaffiliated parents as well had the leastadvantages with respect to sense of peace. Perhaps, this groupmay no longer have access to the supportive aspects of reli-gious faith, in contrast to the first generation secularised. Itshould however be noted that the denominational differencesin the current study were statistically modest or even weak,because of small group numbers in the stratified analyses.

The contemporary society of The Netherlands should becharacterized as highly secularized, and in younger samples,the first-generation secularized represents a large group.Some convictions and remnants of doctrines may persist,along with spiritual feelings, rituals, and new beliefs, suchas feelings about reincarnation. With respect to the needsand strengths of secularized older adults when facing death,future research may include aspects of spirituality and otherdimensions of meaning in life. For those who have beenraised within a religious tradition, inclusion of measures ofintrinsic and extrinsic religious motivation is warranted, aswell as deeper inquiry into the contents of beliefs, to revealwhich church doctrines and which motivations are moresustaining and supportive and which are more depressing.

Salience of religion as reported by the proxy respondent,but not salience as reported by the sample member, was

associated with a sense of peace in the last week of life. Onemay therefore assume that the proxy respondents (especiallythe spouses) used to have similar religious beliefs andpractices as the respondents had during their lives. On theone hand, the results from the current study might show howreligiousness of the proxy respondent helped to cope with theloss of the relative. On the other had, the considerable degreeof personal involvement of the proxy respondents may haveinfluenced the results. The current study focuses, however,on effect modification by a variable that was assessed earlierin life: previous depressive symptoms. Apparently, the globalassessment of mood in the last week of life by the proxyrespondents did not prevent that more or less opposingresults for the nondepressed and depressed still could bedescribed.

One limitation of the current study is that mood in thelast week of life was not directly observed in the respondentswhen they were terminally ill, but was assessed retrospec-tively. For the current sample, Klinkenberg and colleaguesverified some information obtained from the proxy respon-dents with reports from physicians [31]. The proxy respon-dents seemed to provide accurate information with respectto chronic physical conditions. As Addington-Hall andMcPherson (2001) point out in their review about the valid-ity of after-death interviews, some studies provided evidencethat there is little correspondence between the sample mem-ber and the proxy respondent about topics like depressedmood [32]. According to research on the concordance ofpatient and caregiver reports, both patient and caregiverdepression were common predictors of disagreement [33].Although the results of the current study closely examinedfor effects of previous depressive symptoms, further reasonsfor nonconcordance could not be ruled out. The same is truefor recall bias by the proxy respondents, many of whom wereinterviewed after two years. An important concern regardingresearch about the end of life in the general populationremains the difficulty of timely identification of respondents,and if they can be identified, few will be able or allowed toparticipate. Interviews with surviving relatives therefore willremain a source of knowledge about the last phase of life.Another limitation is that both outcomes consisted of one-item measures. One recommendation for future researchis to examine the state of mood more fully. Meanwhile,psychometrically acceptable measures of the quality of thedying experience have become available, such as two versionsof the quality of dying in long-term care instrument [34].A related point is that the current study did not includemeasures on, partly overlapping, concepts such as spiritualdistress, or death anxiety [6, 35]. Measures on emotionalaspects of religiousness, spirituality, and secular sources ofmeaning in life may be included in further research.

The current results suggest that vulnerability to depres-sion is an important aspect for the direction of the relation-ship between religiousness and mood in the last phase of life.It should be underlined that replication is desirable, bothemploying quantitative and qualitative research methods,before any recommendations can be done to professionals in


the field of palliative care. Recent guidelines and recommen-dations for the quality of spiritual care—as a dimension ofpalliative care—provide suggestions for screening questionsto assess spiritual life in patients in palliative care, to keepan eye on spiritual distress or religious struggle, and howto integrate spiritual issues into the treatment plan [36].Verifying the recent history of depressive symptoms mayprovide a cue to detect any religious struggle or othersevere existential doubts, which may possibly represent anadditional burden for those in the last phase of life.

Conflict of Interests

No competing financial interests exist.

Acknowledgments

The data reported on were collected in the context of theLongitudinal Aging Study Amsterdam, which is financedprimarily by The Netherlands Ministry of Welfare, Health,and Sports. The study of religious resources and commonmental disorders was supported by a grant by The Nether-lands Organisation for Health Research and Development(ZON-MW Grant 2003-05769). The results of the currentstudy have been presented at the VIIth European Conferenceof the IAGG, Bologna, Italy, April 16, 2011.

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